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Some pharmacological studies on the spastic mouse.

1 Full-wave rectification and integration of the EMG signal recorded from the hamstring muscles of the spastic mouse was used to evaluate the actions of a variety of drugs on the muscle rigidity of these mutants, animals in which no histological lesion has yet been found. 2 Profound and long-lasting muscle relaxant responses were consistently observed upon the injection of diazepam (2 mg/kg, i.p.) and flunitrazepam (2 mg/kg, i.p.). Such responses were always greater than those obtained upon injection of 40% (v/v) propylene glycol (10 ml/kg) alone, the vehicle for the benzodiazepines. 3 The muscle relaxant action of a low dose (0.25 mg/kg i.p.) of the benzodiazepine Roll-6896 was not shared by the same dose of its enantiomer Roll-6893. 4 Profound and long-lasting muscle relaxation was caused by sodium valproate (696 mg/kg, i.p.). Consistent muscle relaxant responses were also observed upon the injection of pentobarbitone (30 mg/kg, i.p.), but not phenobarbitone (30 mg/kg, i.p.). 5 Other drugs that had little or no detectable effect on the muscle rigidity of the spastic mouse included diphenylhydantoin (30 mg/kg, i.p.) and bromocriptine (10 mg/kg, s.c.) while, in some animals, benztropine (2 mg/kg, i.p.) and baclofen (10 mg/kg, i.p.) increased muscle rigidity. 6 The development of full muscle relaxant responses to flunitrazepam (2 mg/kg, i.p.) and to sodium valproate (696 mg/kg, i.p.) was shown to depend upon mild warming of the animals with radiant heat, a procedure which can increase muscle spindle afferent input to the spinal cord. 7 The results suggest a hyperactivity of stretch reflexes in the spastic mouse, ameliorated selectively by those drugs that enhance the GABA-mediated presynaptic inhibition of such pathways.

Animals↗

Effect of diazepam and desmethyldiazepam in spasticity and rigidity. A quantitative study of reflexes and plasma concentrations.

Benzodiazepines are known to reduce increased muscle stretch reflexes. To investigate the relationship between the necessary plasma concentrations of diazepam and its major metabolite desmethyldiazepam on the one hand and the phasic and tonic ankle reflex activity on the other, 10 mg diazepam was given intravenously to nine patients, seven with spasticity due to multiple sclerosis and two with parkinsonian rigidity. Diazepam and desmethyldiazepam both had a normalizing effect on the increased phasic ankle reflex seen in spasticity. No effect was observed on the increased tonic reflexes in rigidity. The concentrations of diazepam necessary to reduce spasticity ranged between 300-2,200 mg/l and were so high that drowsiness did occur. However, the study may indicate that desmethyldiazepam has a higher potency and a more long lasting effect on the increased phasic reflexes than diazepam.

Adult↗

The effect of the GABA-agonist, progabide, on stretch and flexor reflexes and on voluntary power in spastic patients.

The action of the GABA-receptor agonist, progabide , was investigated in a double-blind study with cross-over to placebo. The stretch and flexor reflexes and voluntary power were measured in 16 patients with spasticity. 2-week treatment periods were used; the median daily oral dosage of progabide was 24.3 mg/kg. The Achilles tendon (T) reflex was significantly suppressed whereas the Hoffmann (H) reflex remained unchanged: the T/H ratio was thus reduced. Hmax /M (direct motor)max ratio and the vibration-induced suppression of the T- and H-reflexes were unchanged. These findings indicate an effect of progabide on the spindles or on the controlling fusimotor system (probably acting on spinal interneurons), whereas influence on presynaptic inhibition and alpha-motoneuron excitability is unlikely. The flexor reflex threshold was increased during progabide treatment and latency at threshold decreased towards normal latency. This indicates some influence of progabide on flexor reflex activity attributed to reinforcement of action of GABAergic interneurons at the spinal level. Isokinetic measurement of voluntary power of knee extension revealed particularly good progress for the fastest movements during progabide treatment, whereas isometric measurement of sustained handgrip remained unchanged, probably reflecting a reduction of spasticity without reduction of voluntary power in non-spastic muscles.

Achilles Tendon↗

The clinical effect of the GABA-agonist, progabide, on spasticity.

In a double-blind cross-over trial of two 2-week periods, the clinical effect of progabide was compared to placebo. 16 patients with spasticity in a stationary phase completed the trial. 14 had multiple sclerosis, 2 hereditary spastic paraplegia. 5 were female and 11 male. The median age was 45.5 years (range 30-62 years). The median daily dosage of progabide was 24.3 mg/kg (range 14.3-32.7 mg/kg). During progabide treatment, there was a reduction in spastic hypertonia (P less than 0.01), a suppression of tendon reflexes (patellar) (P less than 0.01), and a reduction in the frequency of flexor spasms (P less than 0.05). No significant changes in voluntary power were registered. The global clinical impression revealed a therapeutic effect in 87% of the patients (95% confidence limits 61-98%). The improvement was judged as medium or important in 50% of the patients (95% confidence limits 23-77%). No side-effects or laboratory abnormalities were seen.

Adult↗

Effect of clorazepate in spasticity and rigidity: a quantitative study of reflexes and plasma concentrations.

The effect on increased myotatic reflexes of desmethyldiazepam, formed from its precursor clorazepate, was assessed in a double-blind cross-over study of 27 days duration. Eight patients with spasticity or rigidity were given placebo or active substance; first in loading doses for 2 days, then 5 mg every 12 h for a total of 10 days. A wash-out period of 7 days was interposed between the 2 10-day periods. Desmethyldiazepam had a normalizing effect on the increased phasic ankle reflexes seen in spasticity, but not on the increased tonic reflex seen in rigidity. The mean concentration of desmethyldiazepam in the steady state was 1227 nmol/l (range 600-1990 nmol/l). The plasma concentration of desmethyldiazepam tended to correlate with the percent decrease in phasic reflex activity (P = 0.08, 2-tailed). A slight drowsiness in 2 patients was the only side-effect seen. In conclusion, desmethyldiazepam given as clorazepate seems to be a suitable medicament in the treatment of spasticity.

Adult↗

Tizanidine versus baclofen in the treatment of spasticity in multiple sclerosis patients.

Sixteen patients suffering from spasticity due to multiple sclerosis were treated with baclofen and tizanidine in a partially blind cross-over study. No significant difference in efficacy was found. The most striking difference was seen in the side-effects: baclofen frequently caused more or less severe muscle weakness and even falling during walking and standing. Treatment with tizanidine produced an apparent improvement of mobility in some patients suffering from moderate or marked paresis associated with a marked spasticity of their legs. Isometric muscle strength did not show any significant changes during either treatment. The different impact of baclofen and tizanidine on mobility and weight support seems to be related to their different site of action in spasticity.

Adult↗

A Dutch family with autosomal dominant pure spastic paraparesis (Strümpell's disease).

Families with "pure" hereditary spastic paraparesis of late onset have rarely been reported. Since the original article by Strümpell in 1880, many "complicated" forms of the disorder have been reported, and the question as to whether a "pure" form exists still arises from time to time. We present a Dutch family with "pure" hereditary spastic paraparesis, involving 15 affected members in three generations. The mode of inheritance was autosomal dominant, with onset of clinical signs in the fourth or fifth decade. Severity of the disease was mild; only a few of them became chairbound in the end. There were no sensory symptoms. Mild sphincter disturbances were mentioned by six patients. A review of the reports on Dutch families is given and arguments in favour of the existence of "pure" hereditary spastic paraparesis are discussed.

Adult↗

Clinical and demographic features of HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) in Rio de Janeiro, Brazil.

In Rio de Janeiro (RJ) most cases of paraparesis of obscure origin are associated with the human T-cell lymphotropic virus type I (HTLV-I). Thirty-four consecutive patients with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) from RJ were evaluated. Most patients came from low socio-economic levels. There was no difference in terms of gender. The main affected racial group was white. A history of sexually transmitted diseases was a major risk factor for HAM/TSP and a positive serology for syphilis was found in 26.5% of the patients. The major clinical findings were of a spastic paraparesis with generalized brisk tendon jerks and bilateral Babinki's sign. Sensation was abnormal in 25 patients (73.5%) and five (14.7%) had a sensory level. Three patients (8.8%) had optic atrophy. The cerebrospinal fluid showed a lymphocytic pleocytosis with a mean total protein content of 0.4 g/litre, and an increased intrathecal IgG synthesis in 59.4% of patients. HAM/TSP and multiple sclerosis (MS) occur indigenously in RJ and some HAM/TSP cases can be sometimes confused with MS. Therefore we propose that, in places where MS coexist with HAM/TSP, HTLV-I antibodies should be sought routinely in those MS suspected cases with prominent spastic paraparesis.

Adolescent↗

Altered inhibitory synaptic transmission in superficial dorsal horn neurones in spastic and oscillator mice.

The spastic (spa) and oscillator (ot) mouse have naturally occurring mutations in the inhibitory glycine receptor (GlyR) and exhibit severe motor disturbances when exposed to unexpected sensory stimuli. We examined the effects of the spa and ot mutations on GlyR- and GABAAR-mediated synaptic transmission in the superficial dorsal horn (SFDH), a spinal cord region where inhibition is important for nociceptive processing. Spontaneous mIPSCs were recorded from visually identified neurones in parasagittal spinal cord slices. Neurones received exclusively GABAAR-mediated mIPSCs, exclusively GlyR-mediated mIPSCs or both types of mIPSCs. In control mice (wild-type and spa/+) over 40% of neurones received both types of mIPSCs, over 30% received solely GABAAR-mediated mIPSCs and the remainder received solely GlyR-mediated mIPSCs. In spa/spa animals, 97% of the neurones received exclusively GABAAergic or both types of mIPSCs. In ot/ot animals, over 80 % of the neurones received exclusively GABAAR-mediated mIPSCs. GlyR-mediated mIPSC amplitude and charge were reduced in spa/spa and ot/ot animals. GABAAR-mediated mIPSC amplitude and charge were elevated in spa/spa but unaltered in ot/ot animals. GlyR- and GABAAR-mediated mIPSC decay times were similar for all genotypes, consistent with the mutations altering receptor numbers but not kinetics. These findings suggest the spastic and oscillator mutations, traditionally considered motor disturbances, also disrupt inhibition in a sensory region associated with nociceptive transmission. Furthermore, the spastic mutation results in a compensatory increase in GABAAergic transmission in SFDH neurones, a form of inhibitory synaptic plasticity absent in the oscillator mouse.

Animals↗

Effect of muscle biomechanics on the quantification of spasticity.

The impact of muscle biomechanics on spasticity was assessed by comparison of the reflex responses of the elbow and metacarpophalangeal (MCP) flexor muscles in individuals with chronic spastic hemiplegia following stroke. Specifically, methods were developed to quantify reflex responses and to normalize these responses for comparison across different muscle groups. Stretch reflexes were elicited in the muscles of interest by constant velocity ramp-and-hold stretches at the corresponding joint. The muscles were initially passive, with the joint placed in a midrange position. Estimates of biomechanical parameters were used to convert measured reflex joint torque and joint angle into composite flexor muscle stress and stretch. We found that the stretch reflex response for the MCP muscle group had a 74% greater mean stiffness modulus than that for the elbow muscle group, and that the reflex threshold was initiated at an 80% shorter mean muscle stretch. However, we determined that initial normalized fiber length was significantly greater for the experiments involving the MCP muscles than for those involving the elbow muscles. Increasing the initial composite fiber length of the elbow flexors produced significant reduction of the reflex threshold (p<0.001), while decreasing the initial length of the MCP flexors significantly reduced their measured reflex stiffness (p<0.001). Thus, biomechanical parameters of muscle do appear to have an important effect on the stretch reflex in individuals with impairment following stroke, and this effect should be accounted for when attempting to quantify spasticity.

Aged↗

The management of spasticity.

Spasticity is a frequent feature of neurological disease in adults and children. Commonly associated symptoms include impaired movement, painful muscle spasms, stiffness and disturbed sleep. Severe or long-standing spasticity may lead to contractures and joint ankylosis, which can severely restrict the patient's care and rehabilitation. Here, we review the management of patients with spasticity, concentrating on the role of drug treatment.

Administration, Oral↗

Mutation analysis of the spastin gene (SPG4) in patients with hereditary spastic paraparesis.

BACKGROUND: Hereditary spastic paraparesis is a genetically heterogeneous condition. Recently, mutations in the spastin gene were reported in families linked to the common SPG4 locus on chromosome 2p21-22. OBJECTIVES: To study a population of patients with hereditary spastic paraparesis for mutations in the spastin gene (SPG4) on chromosome 2p21-22. METHODS: DNA from 32 patients (12 from families known to be linked to SPG4) was analysed for mutations in the spastin gene by single strand conformational polymorphism analysis and sequencing. All patients were also examined clinically. RESULTS: Thirteen SPG4 mutations were identified, 11 of which are novel. These mutations include missense, nonsense, frameshift, and splice site mutations, the majority of which affect the AAA cassette. We also describe a nucleotide substitution outside this conserved region which appears to behave as a recessive mutation. CONCLUSIONS: Recurrent mutations in the spastin gene are uncommon. This reduces the ease of mutation detection as a part of the diagnostic work up of patients with hereditary spastic paraparesis. Our findings have important implications for the presumed function of spastin and schemes for mutation detection in HSP patients.

Adenosine Triphosphatases↗

Science in motion: common molecular pathological themes emerge in the hereditary spastic paraplegias.

The hereditary spastic paraplegias are a group of neurodegenerative conditions that all share the principal clinical feature of progressive lower limb spastic paralysis, caused by either failure of development or progressive degeneration of the corticospinal tract. The conditions are characterised by extreme genetic heterogeneity, with at least 20 genes involved. Until recently, no functional overlap was apparent in the associated molecular pathological mechanisms. However, with recent progress in hereditary spastic paraplegia gene identification, common pathological themes are now emerging.

ATPases Associated with Diverse Cellular Activitie↗

X-linked adrenoleukodystrophy presenting as autosomal dominant pure hereditary spastic paraparesis.

We present a family in which an initial clinical diagnosis of autosomal dominant pure hereditary spastic paraparesis (HSP) was made on the basis of a three generation pedigree in which both males and females presented with a spastic paraparesis. Subsequent biochemical and genetic analysis revealed that the family was in fact affected by the adrenomyeloneuropathy subtype of X-linked adrenoleukodystrophy. In the family described, both males and females were affected by a spastic paraparesis, and there was no male to male transmission, consistent with both autosomal dominant and X-linked inheritance. This report illustrates the importance of assaying very long chain fatty acids (VLCFAs) in any HSP family where there is no male to male transmission.

Adrenoleukodystrophy↗

Hamstrings stretch reflex in human spasticity.

In 16 patients with spastic paralysis the hamstrings stretch reflex was found to increase as the velocity of stretch increased, and generally to subside after movement ceased. These effects are attributable to the dynamic property of the primary spindle ending. The stretch reflex commonly appeared in only the last third of the stretching movement and was maximal as the knee became fully extended. This is consistent with the static properties of the primary and secondary spindle endings, and accounts for the absence of the clasp-knife phenomenon in the spastic hamstrings. The difference in the nature of the stretch reflex in spastic flexor and extensor muscles is best explained by the differential reflex effects of group II afferent fibres which facilitate flexor motoneurones and inhibit extensor motoneurones.

Electromyography↗

Interaction between voluntary contraction and tonic stretch reflex transmission in normal and spastic patients.

Transmission characteristics of tonic stretch reflex (TSR) pathways in both normal and spastic patients have been measured during different levels of sustained voluntary contraction of the biceps brachii muscle. A cross-correlation technique of analysis was used to separate reflex responses from the total electromyographic activity. TSR transmission in normal subjects was observed to change with the level of voluntary contraction; sensitivity to stretch increased approximately three-fold as the subject stiffened the arm by simultaneously contracting flexor and extensor muscles. In contrast, TSR transmission did not alter during voluntary contraction in spastic patients. It is proposed that in spastic patients supraspinal modulation of reflex transmission is impaired because hypersensitive spinal reflexes short-circuit long loop pathways.

Cerebral Palsy↗

Segmental reflex pathways in spinal shock and spinal spasticity in man.

Activity in three segmental pathways was compared in normal subjects, patients with spinal shock, and patients with established spinal spasticity. The Achilles tendon reflex (ATR) was used to estimate transmission in the Ia monosynaptic pathway. Evidence is produced implying that vibration activates motoneurones principally through a polysynaptic pathway. The tonic vibration reflex (TVR) was used to estimate transmission in this Ia polysynaptic pathway. The percentage of the motoneurone pool (M-response) that could be activated by these pathways was used as a measure of transmission. The H reflex (vibration)/H reflex (control) ratio was used as an estimate of the degree of presynaptic inhibition of the Ia monosynaptic pathway. The findings led to the following conclusions. (1) In spinal shock presynaptic inhibition is greater than normal, transmission in the Ia monosynaptic pathway is reduced, and in the Ia polysynaptic pathway virtually abolished. (2) In established spasticity presynaptic inhibition is impaired, transmission in the Ia monosynaptic pathway is increased, but transmission in the Ia polysynaptic pathway never recovers. (3) The failure of presynaptic inhibition associated with spasticity is a gradual process. A hypothesis to explain these findings is proposed.

Achilles Tendon↗

Comparison of dantrolene sodium and diazepam in the treatment of spasticity.

The effects of dantrolene sodium and diazepam were compared in a double crossover study of 42 patients with spasticity due to stable multiple sclerosis. Both drugs reduced the findings of spasticity, clonus, and hyperreflexia, and the complaints of muscle stiffness and cramping. Each drug had different side effects which suggest indications and contraindications for its use in spastic patients.

Clinical Trials as Topic↗